District Swabi Human Development Report District Swabi Human Development Report

District Swabi Human Development Report Addressing Vulnerabilities in Education and Health: Responding to Out-of-School Children and Out-of-Pocket Expenses

Faisal Buzdar AAWAZ

Copyrights AAWAZ Programme @2015

AAWAZ Programme is funded by the UKAid through the Department for International Development (DFID), AAWAZ was conceived initially as a five-year programme, from 2012 to 2017. Development Alternatives Inc. (DAI) is the Management Organisation (MO) for implementing the AAWAZ programme, while Pakistan’s prime civil society organisations: Aurat Foundation (AF), South-Asia Partnership Pakistan (SAP-PK), Strengthening Participatory Organisation (SPO) and Sungi Development Foundation (SF) form the implementation consortium responsible for directly working with communities.

All publications by AAWAZ are copyrighted, however, can be cited with reference.

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Table of Contents

Executive Summary...... 5

Chapter 1: Putting Human Development and Human Development Reports into Perspective...... 7

1.1: Enlarging Choices: The Case for Human Development...... 7

1.2: Human Development Reports: An Overview...... 8

1.3: Key Indicators...... 9

1.4: Key Themes...... 10

1.5:Methodology...... 13

Chapter 2: Human Development in Swabi: What Key Indicators Tell Us...... 14

2.1: Human Development in Khyber Pakhtunkhwa: A Cursory Glance...... 14

2.2: District Swabi...... 15

2.3: Education in District Swabi...... 15

2.4: Health in District Swabi...... 19

Chapter 3: Out-of-School Children and Out-of-Pocket Costs in District Swabi: What Qualitative Data Tell Us...... 24

3.1: Out-of-School Children in District Swabi...... 24

3.2: Out-of-Pocket Health Costs...... 29

Chapter 4: Conclusions and Recommendations...... 35

4.1: Education...... 35

4.2: Health...... 39

Annex A: FGD Guide for AAWAZ District Forum...... 44

Annex B: FGD Guide for AAWAZ Village Forum...... 46

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Acronyms

BHU Basic Health Unit NCHD National Commission for Human Development CPR Contraceptive Prevalence Rate NER Net Enrolment Rate CDS Comprehensive Development Strategy PPHI People’s Primary Healthcare Initiative DFID Department for International Development PSLM Pakistan Social and Living Standards Measurement DHQH District Headquarter Hospital PTC Parents Teachers Council EFA Education for All RHC Rural Health Center FGD Focus Group Discussion SAP Structural Adjustment Programs GDP Gross Domestic Product SDGs Sustainable Development Goals HDR Human Development Report SPO Strengthening Participatory IMR Infant Mortality Rate Organisation IDS Integrated Development Strategy THQH Tehsil Headquarter Hospital KPK Khyber Pakhtunkhwa UC Union Council LHV Lady Health Visitor WHO World Health Organisation LHW Lady Health Worker

MCH Maternal and Child Health

MDGs Millennium Development Goals

MICS Multiple Indicator Cluster Survey

MMR Maternal Mortality Rate

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Executive Summary

Human development emerged in the context of for the people. According to the Health System growing frustration with traditional models of Financing Profile released by the World Health development that were based on a belief in the Organisation (WHO) in 2013, Pakistan spent 6.8 annual growth of income per capita alone. It gave billion dollars on health in one year, 55% of which primacy to people’s wellbeing and turned focus was spent by households. The problem of health to enlarging their choices. At the heart of human related private costs is intimately linked to the development lies a pressing concern for providing state’s priorities, as public spending on health equal life chances for all. This report draws on constituted only 2.7% of the GDP. The report at the basic elements of human development hand undertakes to discuss and highlight the and presents a commentary on the state of key scale of out-of-pocket costs and vulnerabilities social indicators in District Swabi. Concerned associated with them. It does so by examining with addressing vulnerabilities in education and the key issues of public and private healthcare, health, and relying on qualitative data, it further access, poverty, and gender. reflects on the themes of ‘out-of-school children’ The state of key education indicators in Swabi, and ‘out-of-pocket health costs’ in the context of though relatively better, is not very satisfactory. the district and highlights issues characterising Enrolment, literacy, and school completion rates them. Despite numerous achievements globally are low. Pupil-teacher ratio is high and many in the domain of education since the inception primary schools in rural areas lack basic facilities. of the Millennium Development Goals (MDGs), Correspondingly, the number of out-of-children the problem of out-of-school children remains; in the district is not negligible. According to an fifty-eight million children of primary school age estimate, 9.2% children of school going age are (normally between six and eleven years) are still out of school. This can be ascribed to a range out of school around the world. This phenomenon of factors such as lack of quality and access, has a strong gender dimension as well, as thirty- poor infrastructure, and misplaced priorities. one million of the fifty-eight million children are Poverty, child labour, gender discrimination, and girls. The number of out-of-school children in disability also serve as barriers to education. Pakistan is estimated to be twenty-five million. Getting children into school requires evolving This report seeks to build a holistic analysis of the an integrated strategy taking into account both issue and discusses a range of variables central supply and demand factors. This may involve to it, viz.: access, quality, poverty, gender, and building schools, providing for missing facilities, disability. Low investments in health result in upgrading teachers’ skills base, eradicating increased risks and enhanced out-of-pocket costs

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political interference, and offering broad-based prioritising universal healthcare, and allocation of social protection programmes. In addition, resources for the health sector. Resources should special measures need to be undertaken to end be generated and directed towards creating and gender discrimination in education and promote strengthening health facilities at the grassroots, female literacy. Disability is exclusion at its worst. tehsil, and district levels to provide a range of In Swabi, children with special needs remain very services and reduce the frequency of referrals to much marginalised. Steps should be taken to other cities. Reproductive health related services fulfill their learning needs and bring them into should be easily available to the population across the mainstream. What actually is required to the district if the wellbeing of the community is to give a boost to education is a sense of ownership be ensured. Investments in public infrastructure on the part of all the stakeholders, including the will shorten the distances and address the issue government, civil society, political parties, donor of access. Moreover, the private health sector organisations, and media. This will clarify the should be regulated transparently and through assumptions, synthesise efforts, and create the citizen health committees to end malpractices synergy required to bring children into school. like monopolisation, commissioning, profiteering, and producing and selling spurious drugs. Indicators related to health also present a gloomy Addressing vulnerabilities in health will eventually picture. Contraceptive Prevalence Rate (CPR) require prioritising health as a sector and an area in the district is fairly low and the incidence of of intervention, and offering policy prescriptions reproductive health related problems is high. that duly respond to the community’s health Public health facilities are sparsely situated and needs. increasingly failing to respond to the health needs of locals. As a result, out-of-pocket costs for the community tend to be very high. According to a local estimate, health related expenses constitute between 25% and 50% of household expenditure. The percentage for the poorest of the poor is much greater and adds to their vulnerabilities. Out-of- pocket costs are high due to a greater reliance on private health facilities. These facilities and services – including tests, treatment, medicines, and consultation fees – are largely unregulated and have considerably high values attached to them. Dramatically reducing out-of-pocket costs calls for developing a new policy regime,

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Chapter 1 Putting Human Development and Human Development Reports into Perspective

1.1: Enlarging Choices: The Case for Human $6.4 billion to $18.3 billion.2 This sorry situation Development called for redefining development and adopting measures sensitive to the historical contexts of Postwar development for over four decades aid recipient countries, as well as people’s needs remained primarily concerned with economic and aspirations. growth and placed a particular emphasis on the annual growth of income per capita. This focus In the 1990s, after the collapse of Soviet Union intensified further with the arrival of neoliberal and the failure of traditional models of growth, policies in the early 1980s, signaling the intellectual debates about development shifted ascendancy of free market economy couched in towards people’s wellbeing, good governance, the normative term of ‘economic liberalization.’1 and human rights. Arguably, within development, However, this strictly market and enterprise- the most vocal response came from those who centred approach failed to develop a nuanced advocated for a people-centred approach to understanding of development and could not development, one with a pro-choice orientation shine light on its different aspects. The main thrust and based on an inclusive and multidimensional of the policies and programmes conceived under framework. This perspective came to be called this technocentric model remained on ensuring Human Development. Human development growth in underdeveloped and developing was an outcome of the path-breaking work by countries through broad-based structural a Pakistani economist, Dr. Mahbub ul Haq, who reforms, aiming to promote free-market economy pioneered Human Development Reports (HDRs) to create wealth for all in society. Not surprisingly, and sought to go beyond income-based measures the effects of these reforms, formulated under the while defining development. Building further banner of Structural Adjustment Programs (SAPs) on Dr. Haq’s contribution, the Nobel laureate in were disastrous. Though these policy prescriptions economics, Amartya Sen, a philosopher and an sought to address the fiscal imbalances of economist, enriched human development through countries requiring economic assistance, they his ‘Capability Approach’ that introduced his core pushed them further into financial insolvency ideas of capability and agency.3 Essentially, the and indebtedness. International indebtedness spirit of human development is summed up by the of low-income countries increased from $134 2 “Governance and Development,” World Bank (1992). billion in 1980 to $473 billion in 1992. Further, Available at: http://documents.worldbank.org/curated/ interest payments on this debt increased from en/1992/04/440582/governance-development 3 S. Deneulin and L. Shahani (eds), An Introduction to the 1 John Rapley, Understanding Development: Theory and Practice Human Development and Capability Approach: Freedom and in the Third World (Boulder: Lynne Rienner, 2007). Agency (London: Earthscan, 2009).

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notion that it is “about equal life chances for all”. focused approach and all of its four national At the heart of human development lies a pressing implementation partners are rights-based concern for enlarging people’s choices, a principle advocacy organisations. One of the core objectives indispensable for ensuring human wellbeing. of AAWAZ is to stimulate an effective demand for Wellbeing itself is a broad concept and requires social services by enabling the citizens to voice a multidimensional frame of measurement and their opinions.4 analysis for clear conceptualisation and effective The Human Development Report at hand serves operationalisation. as a policy advocacy tool to influence outcomes Operationally, human development is a and help AAWAZ and its partner organisations composite index which measures progress and forums to not only deliver on key promises in economic conditions, life expectancy, and of the programme but also to advance a pro- literacy. Over the years, human development poor agenda by drawing on the basic elements of as a concept has evolved to a considerable human development. It is important to mention extent and at present also focuses on measures here that the two approaches viz. human of inequality, gender, and poverty. The current development and rights-based approach to Millennium Development Goals (MDGs) are also development are not mutually exclusive; rather, based on this approach and undertake to make they are mutually reinforcing and complement progress towards a broad range of capabilities. each other. The upcoming Sustainable Development Goals Since human development focuses chiefly on (SDGs) too follow the same framework and turn people’s freedoms – and not solely on their needs, to the freedoms of individuals and communities as is the case with the needs-based approach – it worldwide. resonates strongly with the rights-based approach 1.2: Human Development Reports: An Overview that proposes a rights-focused framework for development that is about maximising people’s Current Human Development Reports (HDRs) rights.5 It is, indeed, safe to assert that the human are being published to lend support to AAWAZ development paradigm is attuned to the basic in achieving its overall objectives that focus on principles underlying the rights-based approach making Pakistan a ‘stable, tolerant, inclusive, to development. It is the concept of agency, i.e. prosperous and democratic place’. AAWAZ is “a person’s ability to pursue and realise goals a Department for International Development that she values and has reason to value,” that (DFID)-funded project aiming at strengthening 4 AAWAZ: Voice and Accountability Programme. http://www. the democratic process in the country through aawaz.org.pk/ enhanced political participation and fostering 5 S. Deneulin, “Ideas related to human development,” in Deneulin and Shahani ed. An Introduction to the Human a culture of accountability. It has a rights- Development and Capability Approach: Freedom and Agency (London: Earthscan, 2009).

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serves as a common denominator between the 2015. The current reports should serve to bridge two approaches. The connection between human data gaps and help revisit our policy commitments rights and human development was cemented at the national level. It would be a valuable further when the 2000 Human Development opportunity to contextualise debates about the Report on human rights affirmed: ‘Human rights MDGs at the district level. Similarly, these reports and human development share a common vision are coming out at a time when the international and a common purpose – to secure the freedom, community is on the cusp of finalising the agenda well-being and dignity of all people everywhere.’6 for the upcoming SDGs. They can be utilised to draw lessons for future interventions proposed These reports undertake to capture the current under the rubric of the SDGs. Making the most state of a range of human development indicators of these reports will require vigorously framing in the selected districts to be able to provide local specific policy proposals by taking note of the actors in governance such as government line findings. departments, citizens’ forums, community-based organisations, and AAWAZ partner organisations 1.3: Key Indicators with content for evidence-based advocacy. Where These reports comply with the basic elements they analyse data against the basic indicators of of human development and focus mainly on key human development, as discussed below, they health and education related indicators. Income also seek to develop a deeper understanding of measures are also a part of human development, the situation in these districts regarding the two but since in Pakistan we do not have sufficient selected themes of ‘out-of-school children’ and knowledge about the economic activity output ‘out-of-pocket health care costs.’ It is expected produced in each district, we cannot proxy the that findings from these reports will enable civil measure of GDP at that level and generate data society organisations and communities to put on economic indicators. Some of the indicators forward more robust and authoritative arguments discussed in these reports are the same as those about a wide range of social issues. featuring in the MDGs. The framework for these It is also rather strongly hoped that these reports indicators was developed in the pioneer human will provide a perspective from below on progress development reports published by Strengthening towards the MDGs. The realisation of the MDGs, Participatory Organisation (SPO). They are further as is quite evident now, has been fraught with a used in these reports because they adequately myriad of policy, implementation, and resource capture the multidimensional nature of challenges, and seems unlikely by the end of development and wellbeing. They are as follows:

6 “Human Development Report 2000: Human Rights and Human Development,” United Nations Development Programme (2000). Available at: http://hdr.undp.org/en/ content/human-development-report-2000

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Education here discuss issues, barriers, opportunities, and data constraints surrounding these themes. • Net enrolment rate 1.4.1: Out-of-school children • Primary school completion rate Since 2000, expansion of primary education • Adult Literacy rate globally has received a remarkable boost and • Teacher to Student ratio by 2012 the number of out-of-school children of primary school age had fallen by 42%. This • Number of Schools (Primary Schools) has been mainly attributable to the initiatives undertaken under the umbrella of the MDGs • Missing facilities (boundary wall, drinking and the Education for All (EFA) goals. However, water, toilet, etc.) according to a recent estimate, 58 million children Health of primary school age (normally between six and eleven years) around the world are still out of • Infant Mortality Rate (IMR) school. The situation is even worse in the realm • Maternal Mortality Rate (MMR) of lower secondary education where, as of 2012, “63 million young adolescents (between twelve • Doctor to Patient ratio and fifteen years) were out of school worldwide.”7

• Number of BHUs, RHCs, FWW, LHWs Unfortunately, Pakistan is home to one of the largest out-of-school children populations. • Contraceptive prevalence rate (CPR) and Although since 2000 it has sharpened focus on availability increasing enrolment rates and managed to • Missing facilities in hospitals (Doctors, reduce the number of out-of-school children by LHV, Skilled Birth Attendants, etc.) 3.4 million, it still has a long way to go, with 25.02 million children out of school.8 This accounts for 1.4: Key Themes more than one-half of out of school children in In addition to the aforementioned indicators, South Asia. Moreover, girls account for more than these reports seek to explore in detail two key half of this number.9 It is fairly unrealistic to expect themes characterising current debates about 7 “Teaching and Learning: Achieving equality for all: Education wellbeing: out-of-school children and out-of- for All Global Monitoring Report, 2014,” UNESCO (2014). pocket healthcare costs. The exercise at hand Available at: https://en.unesco.org/gem-report/report/2014/ teaching-and-learning-achieving-quality-all#sthash.fx5cAmxH. draws heavily on qualitative data to capture and dpbs 8 “NEMIS (2012-13): National Education Management understand the state of these two important Information system,” AEPAM, Ministry of Federal Education issue areas in the selected districts. The reports and Professional Training, Government of Pakistan. 9 “25 Million Broken Promises: The crisis of Pakistan’s out-of- school children,” Alif Ailaan (Islamabad, 2014).

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considerable improvement in social indicators in in life. Any exception to this outcome can only be the remote regions and districts of the country. treated as an anomaly and does not, and should South Asia already has the highest inequality in not, condone the structural deprivations caused education, and it is these far-flung places that by being out of school.11 are the pivot of this inequality.10 Additionally, The issue of out-of-school children is complex and Pakistan has the distinction of having the largest multifaceted and hence must be scrutinised using urban-rural gap in education in the region. a broad-based framework. While delving into low Poverty exacerbates inequalities in education, enrolment and high dropout rates, we need to with poor households finding it exceedingly look across a range of variables intersecting with difficulty to send their children to school in times the problem at hand. Globally, the following five of crisis. Though data suggests that inequality barriers to education are considered crucial and in education has remained constant, it cannot central to understanding the situation holistically: make us complacent or turn a blind eye to the conflict, gender discrimination, child labour, scale and enormity of the stagnant inequality. language challenges, and disability.12 If anything, rigorous efforts should be directed The HDRs sufficiently shine light on these barriers towards significantly reducing inequalities and as they apply to the selected districts. Relying expanding education to the most vulnerable and on qualitative data and inputs received from marginalised groups in the developing world. civil society activists and community members, The out-of-school-children phenomenon has a they also suggest ways to tackle these pressing strong gender dimension as well, as 31 million issues, such as getting children into school and of the 58 million out-of-school children globally increasing enrolment rates through non-formal are girls. The importance of girls’ education can literacy programs and facilities. Social protection be gauged from the fact that about one-half of programmes can serve as effective means to the reductions in maternal and infant mortality dissuade poor parents from taking their children over the past four decades have been ascribed to out of school. They can further incentivise increased female education. Effective advocacy sending school-age children to school. A detailed campaigns can play a big role in eroding cultural discussion on the issue of out-of-school children practices limiting girls’ participation in the public appears later in this report. sphere. If children of school going age are out of 1.4.2: Out-of-Pocket Health Costs school, they are less likely to fully enjoy a broad range of freedoms and exercise their agency later Among a plethora of problems that countries 10 “Fixing the Broken Promise of Education for All: Findings from the Global Initiative on Out-of-School Children,” UNESCO in the developing world have to battle with, is Institute for Statistics (UIS) and UNICEF (Montreal: UIS, 2015). Available at: http://dx.doi.org/10.15220/978-92-9189-161-0- 11 Ibid. en 12 Ibid.

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the problem of providing healthcare facilities no substantial progress so far has been made to their citizens. Owing to struggling economies towards realising this ideal. and lack of sound governance mechanisms, they Out-of-pocket costs affect low-income households find it increasingly difficult to provide basic and more, as added to the basic healthcare costs advanced medical treatment to their citizens. As are transport expenses. Vouchers, refunds, and a result, many countries in the global south fall microcredit schemes are some of the measures behind on key health indicators. The responsibility through which these additional costs can be of responding to healthcare needs then falls upon covered. Moreover, a robust social policy, citizens themselves, who have to pay a large bulk aiming to provide universal healthcare, can also of their health expenses out of their own pockets. endeavour to provide services at the doorstep According to an estimate by WHO, 44.5% of by spanning a network of basic health units and private expenditure on health in 2012 was out- mobile dispensaries. of-pocket.13 Efficient use of resources is another problem that The issue of out-of-pocket costs is complex and plagues the health sector globally. According to its scope and scale varies from individual to an estimate by WHO, 20-40% of resources spent individual, group to group, and region to region. on health are wasted. Given this considerable At the end of the day, in addition to social policy, waste, it can be argued that if these resources it falls under the purview of development, since were to be utilised efficiently they would go a “education, housing, food and employment all long way in delivering the promise of universal impact on health.”14 Grappling with the problem health coverage. One way to dramatically reduce requires systemic reforms in our policy responses out-of-pocket expenses, particularly for the poor, to a variety of development problems. is to ensure universal health coverage, centering Global commitments on the provision of health on all types of health services such as promotion, services, at least theoretically, are quite clear. prevention, treatment, and rehabilitation. The World Health Assembly resolution 58.33 Pakistan in particular has a very high incidence from 2005 states that “everyone should be able of out-of-pocket costs. According to the Health to access health services and not be subject System Financing Profile released by WHO in to financial hardship in doing so.”15 However, 2013, Pakistan spent $6.8 billion on health in one 13 Global Health Observatory (GHO) Data, accessed on April 26, year, 55% of which was spent by households. 2015. Available at: http://www.who.int/gho/health_financing/ out_pocket_expenditure/en/ The state does not appear to have done much 14 “Health system financing: the path to universal coverage: The World Health Report,” World Health Organisation (2010). to prioritise health care as a key sector for 15 “World Health Assembly Resolution 58.33 (2005): Sustainable intervention. In 2012, public spending on health health financing, universal coverage and social health insurance.” Available at: http://www.who.int/health_ financing/documents/cov-wharesolution5833/en/

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constituted only 2.7% of the GDP.16 A staggering community responses to them. Since serious 63.1% of total expenditure on health consisted of data gaps exist across the country on all levels, private expenditure. this qualitative data is invaluable in informing us about the prevailing situation in these districts The situation is much worse in rural areas where, vis-à-vis the key indicators. It is hoped that these in many places, the state of health infrastructure findings will foster more research on similar is abysmal. This is compounded by rampant issues in different settings nationwide. poverty that hardly allows the rural poor to save something for a proverbial rainy day. Our district reports, among other things, undertake to delve deep into the issue of out-of-pocket health costs at the district level. Based particularly on primary data, they approach the theme at hand from all possible dimensions. Interviews and Focus Group Discussions (FGDs) with communities and duty-bearers enable us to rigorously analyse the problem and subsequently suggest ways to solve it while mobilising both local and national resources.

1.5: Methodology

These reports draw on both quantitative and qualitative data to generate and analyse findings. A considerable bulk of quantitative data on our key indicators comes from secondary sources. These include annual, monitoring, and issue- specific reports, as well as household surveys and data sets released by provincial and federal agencies. Qualitative data in these reports comes from primary sources. Qualitative fieldwork was conducted in the four selected districts viz. Dera Ghazi Khan, Pakpattan, Swabi, and Dera Ismail Khan. The data mainly focuses on the aforementioned two key themes and covers

16 GHO Data.

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Chapter 2 Human Development in Swabi: What Key Indicators Tell Us

2.1: Human Development in Khyber Pakhtunkhwa: indicators.17 We do have the Pakistan Social and A Cursory Glance Living Standards Measurement (PSLM) survey Khyber Pakhtunkhwa (KPK) has received various available to us but it is more helpful for education setbacks in quick succession over the past few rather than for health indicators. However, an decades. It not only hosted a large population attempt has been made to put the latest datasets of Afghan refugees throughout the 1980s and to optimum use. 1990s but also suffered serious human and KPK is the third most populated province in the economic losses in the wake 9/11. In 2009, the country, and was estimated in 2010 to have province had to relocate and encamp 3.5 million a population of 24.7 million.18 Development internally displaced people from Malakand efforts in the province received a boost after Division at the time of a military operation the introduction of the MDGs. The provincial there. Many parts of the province were among government devised a Comprehensive the worst affected when the floods hit in 2010. Development Strategy (CDS) to outline its Militancy in and around KPK intensified around development priorities between 2010 and 2017.19 that time, diverting the attention of the provincial This strategy aligns itself with the key MDGs and government towards security. Recent military seeks to make progress towards them. In 2014, operations in North Waziristan have led to a mass it was subsumed in the Integrated Development exodus of local population out of the agency and Strategy (IDS)-2014-2018,20 formulated by the into Bannu, a settled district of the province. All new government. However, it is very clear by these factors come together to impinge on the now that the province, despite some progress, is efficiency of social service delivery and the state a long way off on the main targets. For example, of human development in the province. It also its literacy rate is 52%, which is 5 percentage makes it exceedingly difficult for the government points less than a national average of 57%. and development agencies to redirect their focus Female literacy rate is 35%, whereas, the national towards collecting fresh and reliable data to average is 48% - a significant difference of 13 analyse the situation and evolve policy responses. points. Though the overall literacy rate did go up Data gathered through different sources are from 50% in 2008-2009 to 52% in 2012-2013, it either too old or contradictory. Multiple Indicator 17 “Multi Indicator Cluster Survey, 2008,” NWFP. Cluster Survey (MICS) 2007-08 is the last broad- 18 “Millennium Development Goals: Report 2011,” Khyber Pakhtunkhwa. scale province-sponsored effort undertaken 19 “Comprehensive Development Strategy 2010-2017,” Khyber to gather data on a range of important social Pakhtunkhwa. 20 “Integrated Development Strategy 2014-2018,” Khyber Pakhtunkhwa.

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could not secure significant gains for education Haripur District to the east, Attock District of the in the province. The primary Net Enrolment Punjab to the south, and Nowshera and Mardan Rate (NER) of 54% is also not very encouraging Districts to the West. The district lies between and three percentage points below the national the Indus and Kabul Rivers. Its distance from the average. However, it was 51% in 2010-2011.21 provincial capital Peshawar is about 100 km. The The incidence of poverty is also quite high in total area of the district is 1,543 sq km. According the province and suggests that the situation is to the 1998 census of Pakistan, the district had a very daunting. Where in 2005-2006, 29% of the population of 1,026,804, which, according to an population lived below the poverty line, this estimate, had risen to 1,654,000 in 2014. Swabi figure as reported in the CDS document in 2010, consists of four tehsils, namely Swabi, Lahor, Topi, spiked to 39%. and Razzar. Swabi city is the district headquarter.23

The Infant Mortality Rate (IMR) in KPK, according Swabi is a relatively new administrative district, to the MICS 2007-08 survey, is 76 per 1000 live having been declared one in 1988. In the past, births, which is considerably high and falls behind it remained a part of Peshawar and Mardan MDG 4. Under-five mortality rate of 76 per 1000 districts. Pashto is the main language spoken in live births in 2006-07 went up to a startling 100 the district; however, Hindko is also spoken in per 1000 live births in 2007-08. Immunisation some villages. Agriculture thrives in the district coverage in KPK appeared to be making strides and wheat, barley, oilseed, maize, rice, and up until 2011 but suffered a severe jolt after the sugarcane are among its major crops. Abbottabad incident. According to an estimate 2.3: Education in District Swabi in 2011, 73% of children in the province aged between 12 and 23 months had been fully Education indicators for Swabi on the whole immunised. Contraceptive Prevalence Rate (CPR) are less than satisfactory. Low rates appear again is an abysmal 38.6%. Similarly, though to characterise a variety of components in recent data on maternal mortality is not available, education. Total literacy rate in the area is according to one estimate it was 275 per 100,000 50%, i.e. two percentage points less than the 22 live births in 2006. provincial average. Stark differences can be observed between female and male literacy 2.2: District Swabi rates, which are 34% and 68%, respectively.24 Geography, Location and History The situation in rural and urban areas, however, Swabi is situated in Khyber Pakhtunkhwa and is almost even and represented by literacy rates surrounded by Buner District to the north, of 50% and 51% respectively. This phenomenon is rarely seen in districts with a similar level of 21 Pakistan Social and Living Standards Measurement Survey (PSLM) 2012/13. 23 “District Profile: Swabi,” Government of Khyber Pakhtunkhwa, 22 “Millennium Development Goals Report 2011.” Finance and Planning Department. 24 PSLM 2012/13. 15 AAWAZ

human development. Similarly, where Swabi sense. The enrolment rate for girls at this level is perform poorly and have enrolment rates of 7% comes across as battling against education 22% and for boys 31%. Rural and urban gap – very and 6% respectively. indicators in an absolute sense, its performance surprisingly – puts urban areas at a disadvantage in the province, on the other hand, is relatively with an enrolment rate of 18%, whereas that much better. According to the Pakistan District of rural areas is 29%. It would be instructive to Education Rankings issued by Alif Ailaan in 2014, further explore this gap and look into supply and Swabi is ranked 7th out of 25 districts in KPK. This demand factors. means that many districts in the province have far worse rates and ratios in education. Its national ranking is 54 out of 146 districts nationwide. This High dropout rates across different grades and brings about a modest score of 65.68 for the levels do not augur well for the literacy rate in district.25 the district. Therefore, the percentage of those who have completed primary level or higher 2.3.1: Net Enrolment and Primary School is not very high and stands at 43%. This is one Completion Rates percentage point less than the provincial average. District Swabi has an enrolment rate of 67%, Though up until now we did not see staggering which is above both the national and provincial differences between girls and boys in enrolment averages of 57% and 54%, respectively. Even in rates across different levels, the differentials in NER there do not exist sharp gender gaps at the this category are huge. As of 2012-13, only 29% primary level. The enrolment rate for primary of females in the district had completed primary 26 or a higher level.28 The percentage of their male school age girls is 64%, while for boys it is 69%. Though the urban and rural divide is not too stark, counterparts in the same category was 58%. figures are tilted in favour of the latter. Primary At the high school level, the enrolment rate This suggests that even though both boys and enrolment rates of 70% and 66% for urban and plummets to a shocking 7%, with serious girls face almost similar barriers in accessing rural areas respectively point towards service repercussions for a range of human development education, it is increasingly difficult for the latter gaps across different regions in the district (see indicators, particularly those around income to continue their education once enrolled. Finally, figure 2.1). and economic wellbeing. This is below both the according to statistics released by the Annual national and provincial averages of 13% and Status of Education Report 2013, 9.2% children Enrolment rates for the district suffer a steep 10% (see figure 2.3). It undergoes a precipitous in Swabi were out of school.29 This figure is much drop at the middle level and come down to 27% decline for both girls (at 6%) and boys (at 7%). It lower than the provincial average of 14% and (see figure 2.2). Even though this figure is above would be an imperative to investigate this sharp once again testifies to the district’s relatively the national and provincial averages of 22% and decline at the high school level for it appears to better performance in terms of enrolment (see 21%, it is not an encouraging one in an absolute betray trends at the primary school level.27 Both figure 2.4). A detailed discussion on out-of-school

25 “Alif Ailaan Pakistan District Education Rankings 2014,” Alif rural and urban localities, at this level, turn out to children in Swabi features later in this report. Ailaan (Islamabad, 2014). 26 PSLM 2012/13. 27 Ibid. 28 Ibid. 29 “Annual Status of Education Report 2014,” ITA. 16 District Swabi Human Development Report

perform poorly and have enrolment rates of 7% and 6% respectively.

2.3.2: Adult Literacy Rate

The importance of adult literacy and life-long High dropout rates across different grades and learning cannot be overstated. Adults with levels do not augur well for the literacy rate in skills and knowledge enjoy enhanced sets of the district. Therefore, the percentage of those capabilities and functionings. They are less likely who have completed primary level or higher to experience unemployment and are more is not very high and stands at 43%. This is one financially productive.30 District Swabi, however, percentage point less than the provincial average. does not have a favourable adult literacy rate. Though up until now we did not see staggering There are only 43% of adults in the district differences between girls and boys in enrolment who can be considered literate (see figure 2.5). rates across different levels, the differentials in This rate falls behind both the national and this category are huge. As of 2012-13, only 29% provincial adult literacy rates of 57% and 48% of females in the district had completed primary respectively. The scale of gender inequality in or a higher level.28 The percentage of their male this category is no less shocking. There are only counterparts in the same category was 58%. 27% of literate adult females compared to 61% This suggests that even though both boys and males.31 Such an abysmally low literacy rate for girls face almost similar barriers in accessing females is likely to have a serious bearing on education, it is increasingly difficult for the latter multiple human development indicators. Unlike to continue their education once enrolled. Finally, many other districts in the province and indeed according to statistics released by the Annual country, we do not find a glaring urban and rural Status of Education Report 2013, 9.2% children gap in adult literacy in Swabi. The adult literacy in Swabi were out of school.29 This figure is much rate for rural areas is 42% and for urban areas it lower than the provincial average of 14% and is 46%. Moreover, 27% adult females and 60% once again testifies to the district’s relatively adult males in rural areas are considered literate, better performance in terms of enrolment (see figure 2.4). A detailed discussion on out-of-school 30 “Adult Literacy: A Brief to the Select Standing Committee on Education,” British Columbia Teacher’s Federation (2006). children in Swabi features later in this report. Available at: https://bctf.ca/uploadedFiles/Public/Publications/ Briefs/AdultLiteracyBrief.pdf 28 Ibid. 31 PSLM 2012/13. 29 “Annual Status of Education Report 2014,” ITA. 17 AAWAZ

compared to 29% adult females and 63% adult males in urban areas.

2.3.4: Number of Schools (Primary Schools

Keeping up with trends in education in general, the number of primary schools for boys outweighs 2.3.3: Teacher and Student Ratio those for girls in Swabi. There are only 439 primary Primary education is considered crucial to laying schools for girls while there are 601 such schools the foundation for knowledge acquisition and for boys – a noticeable difference of 162 schools. skills enhancement at a later stage. Therefore, Similarly, differentials are also observable in the teacher-student interaction at this level has to be number of female and male teachers. According meaningful and of high quality. In places where to the latest figures available, there are 1,689 pupil-teacher ratio is high, quality in education female primary school teachers in the district, cannot be ensured. Data reveal that in Swabi compared to 2,398 male teachers.34 pupil-teacher ratio is 44:1, which certainly cannot be considered low (see figure 2.6).32 It is even one point higher than the national average of 43:1.33 Teacher-school ratio in Swabi, on the other hand, is 4:1, which is slightly better in relative terms. This implies that primary schools though not so well resourced are nearly not as understaffed as many other districts. The classroom school ratio is 4:1, which suggests that availability of 2.3.5: Missing facilities (boundary wall, drinking classrooms across different grades is certainly an water, toilet etc.) issue requiring immediate attention. Availability of requisite infrastructure and facilities goes a long way in delivering on the promise of universal primary education. Schools 32 “Pakistan District Education Rankings 2014” and other educational buildings have been shown 33 “Pupil-teacher ratio, primary,” Catalogue source: World Development Indicators, UNESCO Institute for Statistics. 34 “NEMIS (2012-13)”

18 District Swabi Human Development Report

to play an important role in parents’ decisions regarding sending their children to school.35 This factor becomes even more crucial in the case of girls, for parents are certainly reluctant Schools with sa factory building to send their daughters to school with missing facilities.36 Provision of drinking water is ensured in about 87% of the schools, though the quality of water is not known (see figure 2.8). Similarly, 2.4: Health in District Swabi this percentage also suggests that at least 13% of schools in the district have no access to a 2.4.1: Infant Mortality Rate (IMR) facility as basic and important as water. Security of schools and school children is increasingly Recent and reliable district-level data on child becoming a pressing concern, particularly in mortality (whether IMR or under-five mortality the wake of attack on the Army Public School in rate) is not available in Khyber Pakhtunkhwa. Peshawar on December 16, 2014. The fact that Neither the last MICS report nor PSLM datasets Swabi is a district in militancy and terrorism- report on this indicator at this level. However, affected KPK, having a secured premises assumes certain inferences can be drawn and analysis built more importance. Subsequently, 91% of schools from current and previous provincial averages. in Swabi have a boundary wall and do not operate MICS-KPK 2008 reveals that the Infant Mortality out in the open. Rate (IMR) in the province was 76 per 1000 live births.38 A gender comparison suggests that The number of schools with a single classroom females have had higher mortality rate of 79 is very low in the district, as only 3% schools compared to 73 per 1000 live births for males are considered to be falling under this category. (see figure 2.9). Rural-urban differences in child However, the percentage of schools with only one mortality also come to the fore. The figure for teacher is relatively high at 11%. Surely, this does urban areas was 62, compared to 78 for rural affect a considerable swathe of the population areas. The province does not seem to have made and calls for urgent action. Overall, the proportion significant progress in child mortality as in 2001 of schools where building condition is deemed IMR stood at 79.39 satisfactory is 86%.37 The under-five mortality rate is even higher in the province and represented by the figure of 100 per 1000 live births. Gender-related mortality differences again emerge, and indeed 35 “Fixing the Broken Promise of Education for All” 36 “25 Million Broken Promises” 38 MICS-KPK (2008) 37 “NEMIS (2012-13)” 39 MICS-NWFP (2001)

19 AAWAZ

become starker. The mortality rate for males in lower than both provincial and national averages this category is 95, compared to 105 for females. of 76% and 82% respectively. Gender differences, Rural-urban differences also persist. The under- however, cannot be overlooked, as the average five mortality rates for rural and urban areas are for females is 75%, compared to 89% for males. 104 and 77, respectively. This disconnect can Similarly, rural-urban gap is also manifest. In rural partly be attributable to the fact that 17% of areas, the immunisation rate is 80%, whereas in the population of the province is not covered by urban areas this is 96%, a plain difference of 16 Lady Health Workers (LHWs), and a bulk of that percentage points.41 population lives in rural areas.40

2.4.2: Maternal Mortality Rate (MMR)

Child mortality is intimately linked to a range of Maternal Mortality Rate (MMR) is an indicator services provided to make the overall conditions for which data is hard to find. No data on district safe for children. Immunisation is an invaluable averages for KPK is available. Even though the step in order to reduce child mortality and ensure provincial average is known, it is not very recent the safety of children. Fortunately, district-level and is subject to doubts considering the indirect data on full immunisation in KPK is available. nature of data collection techniques for this However, it is not very recent and does not take indicator. The last available provincial average cognizance of the incalculable damage done for MMR comes from MICS 2006-07.42 Figures to immunisation campaigns in recent years by indicate that the mortality rate at the time was militants. Still, through what is available we can 275 per 100,000 live births. There are other gauge the scale of immunisation and what it indicators, however, crucial to understanding might suggest for child mortality or lack thereof MMR in the absence of direct data. Reproductive in the district. According to data released health indicators can be assessed to speculate through the PSLM 2012-13, the percentage of on the state of maternal health or lack thereof. children aged 12-23 months that have been fully In this regard, three measures, namely antenatal immunised was 83% (see figure 2.10). This is and postnatal care provision and during-delivery

41 “PSLM 2012/13” 40 “Khyber Pakhtunkhwa Millennium Development Goals 2011.” 42 MICS-KPK 2006-07

20 District Swabi Human Development Report

assistance, are of considerable importance. In low 0.08% turned to a traditional birth attendant District Swabi, 33.8% of married women aged 15- while 92.3% received no postnatal care at all. 49 saw a doctor for antenatal care, 5.3% of women Provincial averages for the same were 11.1%, turned to LHVs or LHWs, while a significant 59.9% 0.08%, 0.07%, and 87% respectively.44 were reported to have had no antenatal care.

Figures around during-delivery assistance also 2.4.3: Number of Hospitals/Healthcare Facilities point at serious service gaps (see figure 2.12). District Swabi has a population of 1,654,000, Only 26.6% of women received assistance from which certainly cannot be considered small. a doctor during delivery, 7.3% of women were This calls for a corresponding presence of health helped by an LHV or LHW, 30% were reported facilities. However, when we cast a glance at the to have hired the services of a traditional birth number of facilities available in the district, it attendant, while 2% received no assistance appears to be disproportionately small. There are whatsoever. The provincial averages, on the other only 4 hospitals in the entire district. The number hand, for the same are 33.4%, 5%, 25.7%, and 9% of dispensaries is 13, while 4 Rural Health Centers respectively.43 (RHCs) are currently serving the community in rural areas and 40 Basic Health Units (BHUs) operate across the district. There are only 2 TB and 1 leprosy clinics available. The number of Maternal and Child Health (M.C.H) centers is 3.45

Figures for postnatal care are even more disturbing (see figure 2.13). Only 5.6% of women in Swabi said they received some kind of postnatal care form a doctor. Only 1.3% approached or were approached by an LHV or LHW. An incredibly 44 Ibid. 45 Department of Health. Government of Khyber Pakhtunkhwa. 43 MICS-KPK 2008 See http://www.healthkp.gov.pk/.

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Table 2.1: Number of Hospitals/Healthcare Facilities

Type of Hospital Total No. Hospital 4 Dispensaries 13 Rural Health Centers (RHCs) 4 Percentage of demand for contraception satisfied Basic Health Unit (BHU) 40 is 56.7 (see figure 2.15). This can be contrasted TB Clinic 2 with the provincial average of 59.5% - considerably Leprosy Clinic 1 higher than that for Swabi. Maternal and Child Health Centers 3 (M.C.H)

2.4.4: Contraceptive Prevalence Rate (CPR

Gaining access to data on contraceptive prevalence rate (CPR) is fraught with challenges. Most of the figures available are very old and do not reflect the current situation. MICS 2008 is 2.4.5: Missing Facilities in Hospitals the only document with figures on this indicator. Even subsequent provincial development and Missing facilities in hospitals is another problem MDG reports rely on this source. In District Swabi, which impinges on various other health indicators. the number of women using contraceptives or District Swabi, unfortunately, does not seem to showing inclination towards using them is quite be faring well in this area either. According to the low (see figure 2.14). Only 22% of women appear KPK Health Facility Assessment 2012, the district to be using any modern method. The number for struggles to maintain a competitive position any traditional method is 18.5%. Overall, 40.4% on the Health Facility Index (see figure 2.16). of women use at least some kind of contraceptive In fact, some of the scores are very discouraging. method. The provincial averages for the same are The assessment shows that the Basic Health 23.6%, 15%, and 38.6% respectively. This means Units (BHUs) in the district are considerably more or less Swabi can be placed slightly above lacking in various health facilities. Swabi scored the province average. 65 on a scale of 1 to 100 for average availability of inputs for BHUs. The assessment considered the components of infrastructure, human resources, equipment, drugs and supplies, and support services.

22 District Swabi Human Development Report

The district’s performance against the category of missing facilities in Rural Health Centers (RHCs) drops to 51. The score goes up for the District Headquarter Hospitals (DHQHs) and reaches 66. However, massive differences appear between the DHQHs and the Tehsil Headquarter Hospitals (THQHs). In the case of the latter, the score plummets to 28. This is a colossal difference and speaks volume about the situation regarding missing facilities in hospitals at the tehsil level. A high score for DHQHs suggests that the district headquarter receives more attention in terms of resources and efforts than the peripheral areas in the district.

Swabi’s score for a range of health facilities are disparate and imply both improvement and neglect. Tehsil hospitals definitely need more resources and attention from the health department. Due to a large number of missing facilities at the tehsil level, one can see the potential to translate these into deterioration in various social indicators, particularly those pertaining to health.

23 AAWAZ

Chapter 3 Out-of-School Children and Out-of-Pocket Costs in District Swabi: What Qualitative Data Tell Us 3.1: Out-of-School Children in District Swabi on transportation. This phenomenon further has According to the Annual Status of Education a strong gender dimension and girls face acute Report 2013, 9.2% children in Swabi were out of structural and service deprivation. There are more school. This figure may seem small, compared to girls out of school than boys. Understanding the percentages from other districts in the province, problem of out-of-school children necessitates but it actually means thousands of children out looking into a host of issues that characterise it. there, abandoned and left out by the system and 3.1.1: Public Educational Facilities society. Across the district, one finds children out of school, tilling the land by the sweat of Schools as a site of learning play a big role their brows, grazing cattle, working in brick kilns in attracting students. Our interviews and and auto workshops, and trapped in domestic discussions with the community revealed that drudgery and household chores. The community, many a government school in the district had however, contests the figure mentioned above and only two rooms and on average of two to three contends that the actual number of out-of-school teachers. Some schools do not even have subject children is much bigger. For example, Haryan is a specialists and those subjects are taught by village situated in UC Anbar, which is about 25 km teachers trained in other disciplines. This places away from Swabi city. One expects the number of serious constraints upon service delivery. out-of-school children in a settlement close to the Most of the schools cater to the needs of a big district headquarter would be considerably lower. village or more than one village. When students However, according to estimates made by locals, come to schools in large numbers, they are met there are at least 30% of children out of school. with fewer teachers and facilities. Sometimes The problem of out-of-school children affects there are schools where even some of the most various differently and has varied manifestations. basic facilities are missing, thus discouraging The poor in the district seem to be worst hit students from attending classes regularly. For segment of society. They cannot afford to send instance, there are quite a few schools in the hilly their children to school beyond a certain point areas where electricity is not available. Learning and are not convinced of the potential dividends and attending schools in harsh conditions of education. People living in rural areas are become very challenging. Though the incumbent already at a disadvantage owing to scarce government has adopted a ‘six rooms, six educational facilities, and have to prioritise the teachers’ school policy, its implementation is yet education of children by spending extra money to take place. These conditions have encouraged

24 District Swabi Human Development Report

private schools in Swabi to mushroom, making 3.1.3: Poverty and Child Labour it even more difficult for the children from poor Poverty is a huge and highly disempowering households to go to school. Even the children of barrier that not only stops children from going most duty-bearers go to these private schools. to school but also drags them into the practice 3.1.2: Quality of Teaching of child labour. Poor households in both rural and urban areas sometimes find it exceedingly Quality of teaching is another area that reduces difficult to afford to send their children to school, the prospects of getting children into school. It and when they are convinced that the dividends is a common perception that teachers generally of education are far from certain, they tend lack basic skills required to impart and foster to drive their children into child labour. Local learning and transfer knowledge. Their skills and estimates suggest that at least 35% of dropouts competencies are either undeveloped or not in the district are because of child labour. Child harnessed to a point where they can effectively labour may take several exacting forms. In district help young learners acquire basic literacy skills. Swabi, children of school going age involved in This problem is more acute in rural areas, in both child labour may be expected to work as brick public and private schools. Even the education kiln workers or participate in tobacco or field department understands that senior teachers cultivation. In urban areas, they can be found in particular lack skills central to teaching new working at food outlets or auto workshops – curricula. workplaces with low entitlements and taxing Another factor that both the community and conditions. duty-bearers thought kept children out of school Once a child productively becomes a labourer, it is the behaviour of teachers. Though corporal is tremendously difficult for him or her to break punishment is officially prohibited, it is still out of it at a later stage. Though there are more practiced in quite a few schools in the district male children than female ones working in both and serves to damage children psychologically. A informal and formal sectors as labourers, the latter sizeable number of parents interviewed were of too are expected to actively carry out domestic the opinion that in public schools in particular the chores to contribute to household economy by attitude of teachers was such that it discouraged getting involved in economic activities such as learning and turned school into a place where embroidery, sewing, crocheting, and knitting. a child dreads going. The effects of this could be serious. Making children run errands for 3.1.4: Gender Discrimination their teachers or clean the school premises Girls’ education faces numerous challenges in and different equipment and facilities therein, the district and the rest of the country. Certain demoralises students, hurts their dignity, and distracts them from their studies.

25 AAWAZ

cultural attitudes stigmatise female education the meantime, they can be encouraged to attend and seek to alienate them from the mainstream. the nearest school for boys. Even some of the Early marriages, mostly in the rural areas, are education officials believe that by making such encouraged and the prospects of a decent an arrangement we can ensure that no cohort education are doomed forever. Girls’ access to misses going to school. schools is also a serious issue in rural areas and 3.1.5: Disability limits their prospects to receive education. There are fewer schools for girls at every level and if Disability is a major barrier to attaining education they decide to go to a school situated at a fair for children with special needs. Currently, there distance then the odds are already against them. is only one school in Swabi for children affected Creating opportunities for them requires setting by blindness, which can accommodate only up to up new schools and investing in infrastructure. In 25 children. However, even the present strength is far less than the actual capacity of the facility. Box 3.1: Gender Discrimination in Education Since blindness requires providing easy access to such educational facilities, there is a vehicle How stifling the social environment can be available for children. However, ironically, it for girls can be gauged from the story of does not function, for there has been no driver Ayesha Bibi. Ayesha Bibi is aged 20 and lives inducted so far. There is no school for the deaf in a village east of Swabi. She has three sisters and mute in the district and children suffering and three brothers, one of whom is physically from hearing loss or impairment have nowhere handicapped. Ayesha was a bright student to go. and worked hard to earn a matriculation. She wanted to go to college to realize her In villages and distant vicinities on the outskirts true potential but was denied this and not of Swabi city, there is hardly any avenue for the allowed to continue her education. The education of children with special needs. For reasons were poverty and disabling cultural instance, it is estimated that there are about 360 attitudes towards female education. Kin and disabled children in UC Anbar alone, but there is village folk taunted her and her parents about no formal or informal facility available to cater to further studies and derided the very act of their learning needs. In most of the areas, there going to an educational institution. Her other are no estimates available for the disabled, which sisters are unfortunate too, for they too could complicates the situation even more. not complete their education. Ayesha Bibi has now confined herself to her house and has resolved to not think of pursuing further studies.

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3.1.6: Dwindling Enrolment Rates over Different of their children in school. Cultural norms are Levels such that such women do not feel encouraged to interact with male teachers. Thus, if the male child Primary enrolment rates for the district are not of a single parent is lacking interest in studies or too low. We saw in the last chapter that the NER facing some kind of difficulty continuing with his for Swabi is 67%. However, this percentage drops studies, the mother will have problems keeping to a staggering 7% at the high school level. Most track of his progress. of the children actually drop out between the ages of 8 and 12. 3.1.7: Policy Obstacles

Precipitous drops in enrolment at the high school Changes in the provincial educational policy level for both girls and boys are mainly attributable in quick succession have further harmed the to fewer high schools in the district. High schools attainment of education. This is most palpable are normally situated at great distances from each in the field of curricula. Successive governments other and cover a large swathe of villages and changed the medium of instruction from Pashto settlements. Though primary schools are generally to Urdu and then from Urdu to English over a present in localities, it is the high schools that are few years. This made it increasingly difficult for few and far between, thus making it practically children to switch to a new language and for difficult for children to continue their studies teachers to develop competencies commensurate beyond primary or middle levels. According to with the new policy. one education official, there are places in Gadoon During our interaction with the community, it and Topi in the district where there are no middle frequently became apparent that many students, or high schools over 10 kilometers. This problem particularly the rural poor, dropped out because affects poor households the most. It not only of the non-availability of textbooks. As per to increases costs but also makes the lure of child government policy, all children in schools are labour more attractive. Then among the poor provided with books for free, but once a student – rural poor to be more specific – it is female has lost a book or it is damaged, it is difficult children that are hit worst by it. Travelling to high to buy a new one, for they are hardly available school on a daily basis, which sometimes is as far on the market. This discourages some parents as 5 to 7 kilometres, is an unthinkable proposition from sending their children to school to receive for parents of a considerable bulk of girls of school education without books. A ‘book retrieval’ policy going age. It raises transport costs and brings girls does exist on paper but is not practiced at all. As out into the public. per this policy, students being promoted to the Moreover, it is fairly challenging for women who next class return their books from the previous are single parents to closely monitor the progress grade to the school staff. They then share those

27 AAWAZ

books with students who have lost theirs or are in the uncertain security situation appears to be need of new ones. Implementing this policy also making its presence felt here as well. Children becomes harder in the face of change in curricula in the district go to school in an environment of over a short period of time. fear and with a relative sense of insecurity. The Peshawar incident has not only made children 3.1.8: Political Interference more vulnerable, but has also disturbed them Education governance in the past was psychologically. Moreover, some of the measures characterised by political interference and taken in the wake of the incident have had arbitrariness to a great extent. Sanctioning negative effects on children and have made the schools, recruiting staff, and buying equipment environment more securitised. For example, the saw a lot of political meddling and were used to policy of allowing teachers to carry weapons to gain political mileage. Where to build a school school turns out to be exerting a bad influence and where not to build a school was decided on students. We were informed by parents that by political considerations and not practical their children now seemed fascinated with the concerns. Therefore, there are places in the idea of owning and carrying weapons and wanted district where the nearest settlement is several to emulate their teachers. This trend certainly kilometres away from the school. For example, threatens to undo the gains students may have Qadra is a place where there are five schools made over the grades. clustered together with no settlement around at 3.1.10: Responses to Out-of-School Children a short distance. The KPK government recently launched a Though over the years such practices have campaign at the district level to increase dwindled to some extent, owing to a changed enrolment. It is entitled Ghar ‘ Aaya Ustad,’ policy environment in the country, their remnants meaning ‘the teacher comes to your doorstep’. continue to affect service delivery. Still there are The campaign sought to achieve its objectives by schools built on land given by the local influential. raising community awareness about education by Some of these schools are quite far from the holding seminars and talks. It also involved going village they were set up for. The transfers and from door to door and urging parents to send postings of teachers and other education staff, their children to school. Whereas the government however, are still politically determined to a great has been able to project numbers signaling the extent. success of this campaign, the community overall 3.1.9: Security Concerns remains skeptical about it. The people we met and interviewed across the district were of the Though Swabi is not a district directly affected by view that in this campaign the emphasis was militancy engulfing some parts of the province, more on campaign advertisement and publicity

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and delivering talks instead of doing something of the government to provide services to the meaningful and substantive to actually mobilise people. However hard they try to carry out their the community and promote literacy. responsibilities, they never cease to run out of resources, which eventually hampers their efforts To promote female literacy, the government of to improve education indicators. KPK has adopted a particular policy measure that seeks to incentivize education. According to this People seemed sanguine about the upcoming initiative, girls aged between 6 and 10 who attend elections and the degree of decentralisation public schools are entitled to receive a stipend of they would bring. They were of the opinion that Rs. 200 per month. This incentive appears to have local representatives could better deliver social really encouraged parents to send their daughters services as they knew the community better and to school and support their education. However, were responsive to its needs. However, some it is too piecemeal a measure to offset structural feared a resurgence of petty politics, which they barriers and restrain cultural norms. It does not thought would be inimical to transparent and even make up for lack of transport in rural areas. effective service delivery.

Civil society organisations such as the Sungi 3.2: Out-of-Pocket Health Costs Foundation and National Commission for Human The issue of out-of-pocket costs is inextricably Development (NCHD) have been doing their bit linked to the provision of universal healthcare or to promote education and increase enrolment, lack thereof. It is also about the state of health but operating freely and maintaining a strong sector and responses to community’s health presence is fraught with security risks for them. needs. Out-of-pocket expenses rise when there Aid workers are of the opinion that they are are service gaps and policy prescriptions do afraid of being targeted if they too proactively not prioritise health as a sector and an area of pursue a socially progressive agenda. However, intervention. These expenses are hard to bring mobilisation at the grassroots is still possible and down once they escalate, and thus compromise can give a boost to enrolment. Such a campaign the ability of an individual to enjoy different sets was run by the AAWAZ Village Forum in one of its of functionings and invest in their capabilities. villages. It even included a female volunteer. The Rising out-of-pocket costs in fact are indicative of campaign bore results and parents who initially a deeper malaise: a state failing to give primacy seemed reluctant agreed to send their children to to the wellbeing of its citizens and letting them school. slide into an abyss sustained by profiteering and Some education officials believe that dramatic corporate greed. increase in population over the past two Health-related private cost is an issue that decades has seriously undermined the ability manifests itself in both urban and rural areas.

29 AAWAZ

Wherever public service delivery does not match generally patients are asked to buy them from people’s needs, the specter of out-of-pocket costs medical stores. Sometimes the dispenser himself is raised. Though all types of groups are affected runs these stores or their owners have some kind by these costs, it is the marginalised and the of arrangement with the BHU staff that ensures poorest of the poor that suffer the most. Rural the latter their commission. There are only 5 poor and women in particular bear the brunt BHUs in the district that provide services around of this problem and struggle with meeting their the clock under the special program entitled health needs. People’s Primary Healthcare Initiative (PPHI). Still, they are fairly limited in their outreach. 3.2.1: Public Health Facilities Considering all this, whenever someone suffers As stated above, out-of-pocket costs are illness or ailment of mild or serious nature, intimately linked to the state of public healthcare they are taken to health facilities in the district in the country. The effectiveness and functionality headquarter. Over there, they have two choices: of basic health facilities determine how much the either go to the DHQ or a private facility. community members will have to pay from their Overwhelmingly, they opt for the latter. The own pockets. When we take a glance at the health DHQ is functional but again not very effective facilities in District Swabi, the situation does and resourceful. Recently, efforts were made not look promising. We have already assessed to improve the facility, but the results did not the current state of health facilities in Chapter appear to be sustainable. There are fewer 2, and the insights derived through qualitative doctors available and consultation hours small. It methods seem to confirm our analysis. From is difficult getting hold of consultants past 1 pm. BHU and THQ through to DHQ, the picture is one The community generally believes that doctors of unresponsiveness and indifference. Serious in the hospital care more about their private service gaps appear to characterise the health practice. Testing services are either occupied at all sector at the district level. Many of the facilities times, creating a backlog, or are non-existent or are functional, but not effective in an optimum dysfunctional. Even X-rays are mostly performed manner. There are BHUs where doctors hardly outside the hospital. No CT scan facility is available arrive or only cast their presence once a week. in the entire district. The facility for the rest of the week remains at the mercy of the medical technician, dispenser or Though health officials claim that 60% of other staff. medicines are available in the hospital, the community believes otherwise. Patients and Deliveries hardly take place in the BHUs and respondents interviewed for this research claimed antenatal care visits are a rare sight. The that whatever is prescribed to them in the DHQ, availability of medicines is also an issue and they buy it from the medical stores outside. It is

30 District Swabi Human Development Report

because of these reasons that the hospital has Spurious drugs are another matter that associated a very high rate of referrals. A large number of with this unregulated sphere and offset what the patients every day are referred to hospitals in patients spends on their health. Despite quality Nowshera or Peshawar. This tends to increase the control measures being in place, counterfeit costs for the patients and his or her family. The medications are available on the market. These referrals are so frequent that even minor cases medicines, even when not toxic, lead the money are sometimes treated elsewhere. According spent on health to go wasted. The patient sees to one respondent, a particular diarrhea case little recovery and the amount spent on treatment brought to the DHQ was not treated there and is high. the patient was taken over to Nowshera, where it 3.2.3: Out-of-Pocket Costs and the Poor cost him Rs. 5,000. Out-of-pocket costs are a bar on the economy of a 3.2.2: Private Practice as an Unregulated Domain poor household. If someone in such a household Private practice thrives across the district in the falls ill or suffers from an ailment, it jolts the absence of universal healthcare. Be it a village, a entire economic structure of the household. If town or a city, people are made to go to private illness is minor, it can be withstood by readjusting clinics. Since it is largely an unfettered industry, priorities, shuffling heads, or cutting backon the price of services tends to be inflated. One overall expenditure. However, in case of major reason why the cost of different procedures and ailments, sustained injury, or serious illness, the services such as testing and medicine is high is price is exorbitant and fallouts crippling. Loans commissioning. Some practitioners specify the are secured and pledges made. In the absence laboratories and medical stores the patient has of formal safety-nets, this happens through to purchase the services and medicines from. informal social networks and local money- Owners of these facilities then pay commission lending mechanisms. But not everyone manages money to the practitioner for referring them. to access even these. With abject poverty comes Pharmaceutical companies too create monetary powerlessness, and those who are downright incentives for practitioners for prescribing certain poor find it increasingly difficult to obtain loans. medicines. Sometimes these medicines are not They are excluded from the mainstream and required by the patient at all, but he or she is led surrounded by the people who are nearly as into purchasing them in order to increase the sale destitute as they are. Even those who somehow of the product. This practice is widespread and end up borrowing money, spend the rest of their not only increases the treatment costs but also lives repaying the debt. has the potential to create further health hazards.

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size is tied to ensuring financial security in rural Box 3.2: Out-of-Pocket Costs and the Poor and urban areas across the country, family size in the district on average tends to be quite large. Rehmat Khan, aged 50, is a Class-4 employee Correspondingly, it results in escalated health in a public school for girls in a rural union expenses and cripples the household economy. council of Swabi. About 3 years ago, he fell Thus, a large pool of human resources that off the roof and sustained a serious spinal otherwise could have been harnessed to generate cord injury. He was first taken to Swabi and human capital, goes to waste. then to a private clinic in Peshawar. There he underwent surgery and remained admitted 3.2.4: Reproductive Health for three months. His treatment continued Reproductive health is an area that incurs for another two and a half years even after huge costs. Antenatal care visits, as we saw in he was discharged from the hospital. Though the previous chapter, are rare and delivery is now he is back on his feet, he has to walk with overwhelmingly done privately. Those who can a cane. The entire treatment and recovery afford to go to a gynecologist, look to spend process cost him Rs. 800,000 (0.8 million), an between Rs. 15,000 to Rs. 50,000 depending on amount he borrowed over time from different whether it is a normal delivery or a cesarean people in the village. He has two children and section (C-section). The rest, constituting the is now left to pay off the loan from his meager majority, turn to traditional birth attendants, salary of Rs. 10,000 a month. He now finds which, on average, may cost Rs. 5,000 to Rs. 6,000. himself with his back against the wall, and the And there is no guarantee that the traditional going is indeed very tough for him. birth attendant would be skilled. Sometimes they barely have any prior experience. One even hears Sometimes healthcare costs rise at the expense of private delivery facilities in the district run by of other facets of individual wellbeing. Nutrition veterinary physicians. It has been reported that is another area that appears to suffer from this. there are union councils where there are no In poor households, if a large amount is spent on LHVs, and women are left to resort to traditional health, it is ensured that it is made up by taking reproductive health measures. Then there are up austere measures such as cutting back on one’s places in the district where the LHVs, instead daily food intake. This practice, when observed, of doing cases in BHUs, run their private clinics entails serious consequences for one’s health in and extract fees from local people. Moreover, the long term. even where there are LHVs, they are assigned additional responsibilities such as running the Population features also seem to play an polio campaign and providing security to the important role in increasing or decreasing the female staff at polling stations before and during health costs. Since maintaining a large family the local government elections.

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Relatively well-off households in rural areas hardly knew about this intervention; those who prefer to take women to gynecologists in the did, considered the financial assistance too tehsil or district headquarters. But it raises the insufficient. cost for them. If someone does not own a vehicle 3.2.5: Out-of-Pocket Cost Estimates and the delivery case is complicated, requiring expert assistance, they have to rent a car or a Multiple contributing factors work together to van to take the woman to the city. Depending on raise out-of-pocket health costs. Even though the distance between the origin and destination, the BHUs do not operate too efficiently, going private transport may cost a considerable amount there for a check-up or treatment may cost an of money. From the farthest corner of Swabi to average wage earner or a peasant a considerable the district headquarter, the fare may range from amount. The consultation fee is only Rs. 5, but Rs. 4,000 to Rs. 5,000. Therefore, under such costs of tests and medicines tend to be high. If circumstances, those who cannot afford to pay someone is suffering from high fever or a strep for transportation and other costs have to rely throat, total expenses could go up to Rs. 1,000. on local help, which may turn out to be fatal. In case of serious illnesses or health problems, Deaths related to delivery, consequently, are not the patient is necessarily initially taken to Swabi. an uncommon sight in the district and maternal Tehsil headquarters are scantly preferred as sites mortality, at times, is a concomitant of absolute of treatment. This certainly increases the toll. poverty. Over there, as we know, normally the patient has to settle on a private clinic. However, even if he or The government of KPK has recently rolled out a she ends up in a government facility, an imminent scheme entitled ‘Sehat Mand Maa, Sehat Mand referral or a delayed response threatens to Bache’ or ‘healthy mothers, healthy kids’ in order elevate the cost. These expenses usually include, to provide financial support to pregnant women among others, transportation, laboratory tests, from low-income households. According to this medicines, consultation fee, stay in the clinic or scheme, each pregnant woman will be required to hospital, and food. pay four visits to a public health facility to receive antenatal care. She will be given Rs. 300 on each The cost of the entire treatment process soars visit. If the delivery takes place in a public facility when these additional costs associated with the or through midwife, the woman will be given travel, food, and stay of those who accompany Rs. 1,000. In case of paying a postnatal visit, she the patient, are included. Sometimes, their will be entitled to Rs. 500. The government has number is one to two, and sometimes, in case been actively disseminating information about of a female patient, three to four, depending on this programme and expects an encouraging the distance from residence and the nature of response. However, the communities we visited ailment. A woman in her mid-sixties fell terminally

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ill and was admitted to hospital in Swabi. From a non-productive area not needing redistributive there, she was referred to Mardan and then on benefits, encourages private practice, which raises to Peshawar. Four attendants accompanied her the costs for the community to an enormous and she remained hospitalised for 7 to 8 days. extent. Private practice is largely unregulated and Attendants’ expenses and her own treatment and prone to all kinds of malpractices, ranging from stay cost her family a fortune, but even this could profiteering and commissioning to substandard not save her life. She died in the hospital without and, at times, fatal response to quackery. even ever finding out what ailed her. Understandably, linked to financing is the area of Estimates of out-of-pocket costs vary from human resources. Health departments in general household to household, group to group and suffer from shortage of staff and fail to ensure locality to locality. A survey is required to establish the presence of doctors in all of the public health monthly or annually health related expenses facilities across the district. Doctor-patient ratio is per household. Still, we have local estimates fairly high and a number of positions for doctors suggesting the scale of out-of-pocket costs. There are vacant. A robust response is required to fill were households in both rural and urban areas this gap and extend the outreach of healthcare that maintained that health expenses constituted services. at least 25% to 30% of their expenditure, whereas in some cases this figure was 50%. The proportion of out-of-pocket costs relative to income and expenses was higher among the poor.

3.2.6: Constraints

A whole range of factors fundamentally raises out-of-pocket costs for the community and compromises public service delivery in health. Undoubtedly, health financing is a domain, which in Pakistan has not seen significant inflows. Spending on health constitutes a fraction of the entire GDP. A great bulk of this paltry allocation goes into staff salaries and recurrent costs. These resource constraints deal a blow to the ability of duty-bearers to efficiently execute their responsibilities and provide relief to the people. The government’s treatment of health sector as

34 District Swabi Human Development Report

Chapter 4 Conclusions and Recommendations

4.1: Education so that they had vital information. Particular Low enrolment rates, missing facilities, poor attention should be paid to enrolling girls. This quality of teaching, and a large number of out- may require mobilising Parent Teacher Councils of-school children are telling signs of misplaced and other community forums to raise awareness priorities, missed opportunities, and deepening about female literacy and engage the parents. exclusion. It is mainly at the district level that Enrolment rates for the district suffer a steep drop the effects of policies and governance practices at the middle and high school levels. High dropout become visible. Responding to challenges in rates across different grades and levels do not education requires holistically identifying and augur well for the literacy rate in the district. As analysing the problem and creatively seeking suggested in Chapter 2, it would be imperative viable solutions. The discussion in the previous to take this sharp decline at the high school level chapters informs that following are the areas in seriously. This issue, in fact, is tied to the numbers which concerted efforts and systemic reforms are of middle and high schools in the district. Schools required to improve key indicators in education at these levels are not present in all areas and and effectively respond to the problem of out-of- children have to travel a considerable distance. school children at the district level. This raises the cost, and children from low-income 4.1.1: Enrolment rates or poor households find it increasingly difficult to Low enrolment rates at the primary level are continue their education. It arguably affects girls a matter of grave concern. It is at this level the most as in a socially conservative environment that the foundation for later learning is laid. it is fairly challenging for them to travel to a school The figure of 67% for Swabi, though above the situated in a different neighbourhood or village. provincial average, is not promising in absolute It was seen in many parts of the district that at terms. It needs to be improved and consolidated times people have to prioritise the education subsequently. Efforts to increase the enrolment of their children and move to the tehsil or rate must take into account all the barriers to district headquarter. It causes displacement and basic education. The government needs to ensure relocation costs are sometimes very high. More that the enrolment campaign is carried out with resources should be directed towards building a focus and diligence and that the most excluded network of schools at all levels to provide equal groups and individuals are reached out without opportunity to all children. fail. It would help the education department if It came to the fore that when children go to birth registration records are shared with them school, they find fewer teachers there. In places

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where pupil-teacher ratio is high, quality in All the stakeholders, including community, education cannot be ensured. Data reveal that parents, employers, and state authorities, will in Swabi pupil-teacher ratio is 44:1, which is eventually have to come forward. Studies should certainly not low. To tackle this, vacant posts for be undertaken to assess the scale of child labour teachers should be filled on an urgent basis, and a in the district and the causes behind it. Vigilance policy should be evolved to ensure that adequate committees, consisting of government officials, human resources are available in the education school staff, parents, community activists, and department. employers such as brick kiln owners, should be set up to be able to dramatically reduce the incidence 4.1.2: Quality of teaching of child labour. Or if there are already such Quality of teaching is central to achieving critical committees and forums in place, they need to be outcomes in education. Findings in this report revived, reinforced, and strengthened through suggest that teachers generally lack basic skills increased focus. Non-formal schools, learning required to impart knowledge and learning. Their centers and facilities should be established to competencies are either undeveloped or not engage with the out-of-school children involved harnessed to a point where they can effectively in labour. Incentives should be provided to these help young learners acquire basic literacy skills. children for attending school. Moreover, whatever This calls for formulating a robust response to other mechanisms to curb child labour have been the training and capacity development needs of devised or proposed need to be enforced with a the teachers. Such a response should focus on political will. Only then might we be able to get both pre-service and in-service training needs. these children into school and give them the In addition to harnessing the skills of teachers opportunity to build a bright future. and helping them acquire innovative pedagogies, 4.1.4: Girls’ education it is also very important to remind them about developing a non-judgmental approach towards Enrolment rates in Swabi are lower for girls than learning and teaching, and abstaining from for boys and there are more girls out of school harmful practices like corporal punishment. compared to their male counterparts. Both service and demand barriers collude to exclude a 4.1.3: Child labour large bulk of girls from schooling and education. Poverty and neglect on the part of the authorities Stories heard from girls while writing this come together to push children into child labour. report are harrowing and speak volumes about This dehumanizing practice steals childhood from opportunities being denied to them. This affects them and denies key functionings and capabilities not only the girls but the wider society as well essential for enjoying a balanced and fulfilling and involves serious consequences for a whole life. To combat this, bold measures are required. range of human development indicators. Broad-

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based and genuine efforts are needed to promote in education. Sessions should be held with female literacy and allow girls to attend school. parents and communities to raise awareness The implementation of Article 25-A would bea about female literacy. An innovative approach, huge step in this regard. Moreover, the provincial drawing on critical factors, is required to deal government should take the lead in getting girls with the issue of gender disparities in education. into school and ensuring high retention rates. 4.1.5: Disability This calls for investing in education and setting up more schools for girls. The government should Disability is a serious barrier to education, also take seriously the issue of access and scale up affecting children with special needs. Sadly, the efforts to reduce distances between communities disabled are not part of the mainstream and and schools. This may involve allotting land for their educational needs go unfulfilled. They are the school against criteria established by both not only excluded but invisibilzed too. Data on the community and duty-bearers. Road networks their number, nature of disability and literacy should be built to link villages and settlements status is hard to get. Most of the children with and improve students’ access to places of special needs are forced to stay at home and learning. Female students in both rural and urban eke out a forlorn existence. There is only one areas should be provided with transportation school in Swabi for the blind children but that for free or on a highly subsidised basis. They are too is not effective in responding to the learning rights-holders and entitled to such facilities and needs of students owing to resource constraints services. and misplaced priorities. First of all, there is a dire need to gather reliable data on the number Giving stipends to school-going girls is a of children in the district with disabilities. commendable step by the KPK government. It NADRA should make convenient the process of needs to be consolidated and universalized and registration for the disabled. Then a coherent made more substantial by increasing the value strategy needs to be formulated to identify the of the assistance. These policy responses and learning needs of the children and understanding practices will not yield results if the demand how they can be met. The issues of transport, barriers are not taken into account. The data counseling and social support must be taken into revealed that certain cultural norms and practices account. Institutional development, resource act to block girls’ access to education. Female mobilisation, and awareness raising need to be education is stigmatised and early marriages done simultaneously. Community organisations are encouraged. Effective advocacy campaigns and concerned departments should collaborate can play a big role in eroding cultural practices with each other on finding ways to give a sense limiting girls’ participation in the public sphere. of inclusion to children with special needs by Therefore, all the stakeholders need to come up providing them quality education. with a joint strategy to end gender discrimination

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4.1.6: Continuity in policy measures further incentivise sending school-age children to school. Policy continuity is an ingredient that ensures sustainable gains and a wider impact. However, in 4.1.8: Curbing political interference the case of KPK, what we have witnessed is quite Electronic and social media have created a milieu the opposite. Sudden and continual changes in in which issues are discussed and concerns raised. curricula create disruptions and serve to reverse This has led to a changed policy environment, progress made over the years. Since education is which is characterised by debate and relative the cornerstone of a broad-based socio-economic openness. Education governance in the past was development, a provincial consensus is required rife with political interference and arbitrariness. to develop a vision for the future. All the political This has now changed to some extent. However, parties should come together to discuss, debate, transfers and postings of teachers and other and assess the issues fundamental to education education staff are politically determined to a vast in the province. The outcome of such a process extent. Resource allocation, funds transfers, and could be a strategy document outlining the need identification continue to see a great deal future course of action jointly decided by all the of political interference. This needs to change stakeholders. Civil society, too, should be part of if efficiency, transparency and accountability this initiative to seek expert advice and to elicit in education are to be ensured. Participatory the point of view of activists working with the practices – taking on board parents, children, communities. school staff and community representatives 4.1.7: Social protection in education – should be introduced in the governance of education to achieve sustainable gains. For Special safeguards are required for the this, therefore, political interference must be economically underprivileged, socially excluded, completely eradicated. and the structurally deprived. Exclusion and deprivation are so endemic that the duty-bearers 4.1.9: Local governance will have to proactively undertake measures to People in Swabi in general appeared to be offset their effects. Social protection programs pinning hopes on the recently held elections can serve as an effective means to dissuade for local governments. They were of the view poor parents from taking their children out of that decentralised governance would be more school. Vouchers should be provided to parents responsive to their needs. However, it is yet to if they find it difficult to finance the education be seen what difference the new system will of their children. Stipends and scholarships are make. But it is already fairly established that also instrumental in increasing enrolment rates, local governance in a devolved context has the retaining students and enhancing learning. These

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potential to deliver a range of social services need to own education as a sector and an area more efficiently and effectively. Therefore, itis of intervention. This will clarify the assumptions, important that steps are taken to make the most synthesise efforts and create the synergy of this possibility and empower communities at required to bring children into school. This kind of the grassroots. ownership is particularly important at the district level. A forum consisting of district government 4.1.10: Data gaps officials, teachers, parents, and civil society Recent and reliable data on social indicators at representatives should be established to uplift the district level are hard to find. Either there are the state of education in the district and tackle no data on different themes or issues or they are the fundamental issues of literacy, enrolment, outdated and conflicting. Different departments and out-of-school children. After deliberations, and agencies have different estimates of a range research, and consultation, a join strategy of indicators. The education department does should be formulated by the forum members to collect data on a regular basis but it mostly revolves achieve the objectives. Resources, actors, and around figures for staff, students and facilities, milestones need to be identified to hit the targets and fails to grasp the bigger picture. It is also not systematically and efficiently. What is basically cross-checked and, to some, is biased towards required is political will, spearheading efforts to positive conclusions. Therefore, there is a dire promote education and win the hearts of the need for fresh, broad-based and representative children. surveys and research exercises seeking to capture 4.2: Health basic and important information. Such initiatives can be undertaken by both provincial and district The state of health indicators in any country is governments. Data coming from these surveys emblematic of its policy concerns, normative can then be used to draw lessons, analyse the framework for development and strategic choices situation, and inform policy choices. in the social sector. Infant and maternal mortality rates, reproductive health indicators, life 4.1.11: Creating ownership expectancy and immunisation against diseases, Disparities in education are stark and wide. all reflect how the state views the wellbeing A complex web of barriers and causes keep of its citizens. A lack of concern on the state’s thousands of children in the district out of school. part results in the poor state of these indicators This calls for creating a sense of ownership, not and raises the costs for the community. Out-of- only at the district level, but at provincial and pocket costs go up high in places where public federal levels too. Government, civil society, service delivery is poor or non-existent. These political parties, donor organisations, and media costs, as the evidence suggests, create financial hardships and badly affect different facets of an

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individual’s life. Chapter 3 provided us with an mapping of different sources of funding should be estimate of health-related expenses and different carried out. This mapping will identify a range of issues associated with them. Reducing out-of- sources that can be tapped to generate resources pocket costs at the district level requires having for different service delivery components. a sufficient understanding of these issues and Additionally, at the district level, funds can evolving a coherent response to address them. be generated through innovative financing. Following are the domains an integrated strategy All potential avenues of mobilising resources should focus on. domestically should be explored. Now that 4.2.1: Health financing Swabi has a local government, it becomes easier to engage with the actors that may play crucial A meager allocation of 2.7% of the GDP for health roles in resource generation. Funds raised locally is set to decapitate the health sector from the and through innovative financing can be used beginning and raise personal costs for the citizenry. to support services and interventions at the A great bulk of this goes into staff salaries and grassroots. It will further foster inventiveness in recurrent costs. These resource constraints deal the health sector. a blow to the ability of duty-bearers to efficiently execute their responsibilities and provide relief 4.2.2: Public health facilities to the people. Almost all the issues with regards BHUs, DHQs, and other health facilities in the to out-of-pocket costs we discussed above have a district are the main sites of state’s response strong financing aspect. Resource constraints also to people’s needs. It is the effectiveness and abet all kinds of unethical and harmful practices functionality of these basic health facilities that in the domain of health, perpetrated by both determines how much the community will have public and private actors. The first serious step in to pay from their own pocket. District Swabi, the right direction calls for changing priorities and as we have discussed earlier on, does not have directing attention towards health. A robust social fully functional and responsive health facilities. policy, affirming to provide universal healthcare, A number of measures are required to improve can endeavour to deliver services at the doorstep service delivery in this field. BHUs should receive by spanning a network of basic health units and primary attention. First, it should be ensured that mobile dispensaries. But, to this end, public all of the medical staff – doctors, nurses, medical spending on health needs to be substantially technicians, LHVs – observe their full hours in increased and ensured that different sectoral the BHUs. And since rural areas serve as large components receive their due share. Though this pockets of poverty, by ensuring the presence of measure pertains to the federal government, it staff and equipment, much relief can be provided is bound to have dividends at the district level to people over there. Second, basic medicines as well. In the face of financial constraints, a

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should be easily available in the BHUs. This will referral system should be made more systematic. decrease the community’s reliance on medical As of now, it is arbitrary and reduces the scope of stores and provide medicines locally. Third, all locally available health solutions. If a broad range basic facilities should be present and functional. of cases is dealt with at the district level it will Steps should be taken to ensure that the requisite decrease expenses dramatically. testing services are being provided to the people. 4.2.3: Reproductive health Fourth, whatever treatment is mandated for the BHUs should be available to the community. District Swabi’s indicators for reproductive health have not been very encouraging. Delivery related The plight of the THQs presents a different story. deaths and complications are not too uncommon. They are arguably one of the most neglected It is so because there are serious service gaps and health facilities in the district. They even fail to traditional approaches to reproductive health act as the buffers between the BHUs and the hold sway. Antenatal care visits are rare and DHQ. Therefore, efforts should be undertaken to delivery is overwhelmingly done privately. The revive them and ensure effective service delivery LHVs are either non-existent or unavailable owing there. to additional non-reproductive-health-related The DHQ is the largest public facility in the district responsibilities. They are even found to be and is supposed to accommodate people from running their own private clinics. All these factors all over the area. However, owing to a range of jeopardize the lives of women and significantly reasons, it has been struggling with performing increase out-of-pocket costs for the community. that function. First, patients complain of not It would help immensely if the presence of LHVs being able to see a consultant and receive proper and LHWs was ensured in all the UCs and villages treatment. Just like the BHUs, the staff in the therein. DHQ too, should be asked to observe the full The government’s scheme to provide financial duty hours. Second, the plentiful availability of assistance to pregnant women is a welcome sign, medicines is another target that the hospital staff but it is not adequate or significantly supportive. finds hard to achieve. People complain that the By adding the value of assistance, reproductive medicines do come through, but are not available health can be incentivised. In addition, it to the people. If these medicines are substantially should be ensured that if there is provision of provided, it will restore people’s confidence in delivery facility in the BHUs, it is being properly the system and reduce their expenses. Third, used and functional in responding to cases. diagnostic and testing services should be Similarly, traditional birth attendants can also functional in the hospital. Patients have to spend be engaged in improving reproductive health a large amount of money on these services should by offering them specialised courses. This will they avail them outside the hospital. Fourth, the

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create a local pool of skilled birth attendants. manner and pursue ethical means to earn profit, Moreover, special attention should be paid to there are also those who do the opposite and reproductive health facilities in the tehsil and employ unlawful means and harmful practices. district headquarters. Arrangements should be Bold steps should be taken to come down tough made for the performance of C-Sections there on these malpractices. Arrangements such as without sending women to private practitioners commissioning between private practitioners or facilities outside the district. and suppliers, retailers and laboratory owners increase costs for the patients. To protect 4.2.4: Providing relief to the poor consumer rights, a consumer rights protection The poor bear the brunt of health related costs. committee, consisting of local authorities, health They have crippling financial constraints and, officials, community representatives, should be considering their quality of life, soaring health constituted in the district. This committee can problems. Bigger family size adds further to their raise awareness about ethical practices, develop problems. In case of major ailment or a serious a price regulatory mechanism and institute health problem, they have to resort to taking measures to ensure fairness and transparency in loans. Sometimes, these loans are so big that the private domain. The issue of spurious drugs, they spend the rest of their lives repaying them. too, calls for attention. It should be ensured Therefore, significantly reducing out-of-pocket through mutual efforts that the inspection costs should be the government’s foremost of medical stores takes place regularly and priority. This chiefly requires universalising principally. Existing quality control mechanisms healthcare but, in the absence of that, special also need to be enforced in true letter and spirit. measures should be undertaken to provide relief 4.2.6: Improving public infrastructure to the poor. One way to do this is to improve service delivery at the BHU level, as we discussed Out-of-pocket costs affect low-income households above. Another is to provide financial assistance more as transport expenses are added to basic to the poor. This may take the form of a voucher, healthcare costs. Understandably, not all health refund, or cash transfer. Partial health insurance services can be provided at the doorstep. There and microcredit schemes are also viable ways to always will be health concerns for which one has reach out to the most vulnerable groups. to travel a fair distance. But these distances can be made shorter or costs associated with them 4.2.5: Removing monopolies and malpractices reduced by building road networks, connecting Private practice in health has grown to an extent distant villages to the cities and creating better where it has become a self-perpetuating industry. public transport facilities. Investment in roads and Where there are doctors, vendors and laboratory transportation will produce long-term positive owners who offer services in a responsible effects for the rural communities.

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4.2.7: Promotion and prevention

One way to markedly reduce out-of-pocket expenses, particularly for the poor, is to invest in health promotion and prevention. When the community is better aware of the importance of safer environments and healthy attitudes, they tend to value their wellbeing and take steps that, by default, curb many a disease at the source. For this, it is imperative that the health department extends its outreach and offers public health promotion programmes to communities. This would create safer conditions and reduce reliance on practitioners. Special programmes should be instituted to raise people’s awareness about reproductive health issues and build their capacities. A sustained and intensive contact with the populace will help eliminate the context that gives birth to a number of health hazards.

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Annex A FGD Guide for AAWAZ District Forum

Guiding Questions - Monitoring

1. Human development 2.4. What groups are more vulnerable to this problem and why? (probe into 1.1. What do you think is the importance of rural/urban disconnect and potential social indicators (health and education) economic divide influencing the for the overall wellbeing of your situation) community? - Girls 1.2. Are you satisfied with the level of human development in your district? - Exclusion What do you think needs to be changed? 2.5. Which of the following barriers to 2. Out-of-school children enrolment do you think apply in your district and what is their scale and 2.1. What are your views on the percentage intensity? of out-of-school children in your district? (present the percentage/number from - Conflict the report) - Child labour/Poverty 2.2. Why do you think they are out-of- - Language challenges school? - Disability 2.3. Service: - Service quality (the state of facilities/ - Why low enrolment and then buildings, corporal punishment etc.) gradual decrease? - Financing - No. of schools (primary, middle and high) - Cultural barriers

- Teachers (number and quality) 2.6. What is currently being done in the district to address this issue? - Missing facilities - What the government is doing? - Financing (any fee? How much cost? How does government subsidies?)

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- What the civil society organizations and responding well to the health needs are doing? of the community in general?

2.7. What in your opinion can be done to get - BHUs out-of-school children into school? - THQ 3. Out-of-Pocket Health Costs - DHQ (facilities and referrals) 3.1. To what extent is the state able to 3.8. How much do the following items cost? provide you universal healthcare? - Test 3.2. What is the scope of private practice? - Medicine 3.3. How much do people have to spend on health on average? - Surgery

3.4. What percentage of household - Delivery expenses on average consist of out-of- pocket costs? - Transport

3.5. How does this issue affect different 3.9. How much do women normally spend groups differently? on reproductive health? (antenatal, delivery etc.) - Women 3.10. Are you aware of any initiatives - Children currently being undertaken to reduce out-of-pocket costs? - Elderly

- Poor

3.6. What possible factors do you think raise the out-of-pocket health costs? (discuss a range of potential factors such as access (transport), service gaps on the part of the service providers, quality of service in public health facilities)

3.7. Do you think that public health facilities in the district are sufficiently functional

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Annex B FGD Guide for AAWAZ Village Forum

Guiding Questions - Excluded

4. Out-of-school children - Any other group/category

4.1. How many educational facilities are 4.5. Why do you think they are out of there in your UC/village (primary/ school? (hear and jot down their middle/high)? responses and then proceed to the next question to explore the causes/barrier 4.2. What are their characteristics? further) - Girls/boys 4.6. Service: - Number of students - Why gradual decrease in enrolment - Number of teachers over different levels?

- Facilities (no. of rooms/toilet/ - Teachers (skills quality & corporal electricity/provision of clean punishment) drinking water) - Monitoring - Distance 4.7. Demand: What are the local attitudes - Cost (fee and other costs) (any towards education, particularly girls government subsidies?) education?

- Is the School Management 4.8. Which of the following barriers to Committee there functional? enrolment do you think apply in your 4.3. What is the scale of out-of-school village/UC and what is their scale and children in your UC/Village? intensity?

4.4. Who does it affect the most (probe - Conflict qualitatively into the following - Child labour/Poverty categories after hearing their - Language challenges responses)? - Disability - Girls 4.9. If there are any out-of-school girls in - Poor your UC/village, what do they do if they don’t go to school?

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4.10. What is currently being done in your 5.7. How much does a procedure or major locality by different service providers to ailment usually cost? (include transport, address this issue? consultation fee, treatment, medicine and any other expenses) 4.11.What in your opinion can be done to get out-of-school children into school? 5.8. How do they manage those costs generally? 5. Out-of-Pocket Health Costs 5.9 How do out-of-pocket costs affect 5.1. What health facilities are available in different groups differently? your UC/Village? - Women 5.2. What are their characteristics? - Children - Type of facility - Elderly - Number of staff - Poor - Equipment/facilities 5.10 How do out-of-pocket health costs - Cost (receipt, test, medicine etc.) affect reproductive health issues? (ask - Distance/outreach about antenatal care, delivery, postnatal 5.3. Do you think those health facilities are care, visits by LHWs) sufficiently functional and responding 5.11 How do out-of-pocket health costs well to the health needs of the affect other areas of household economy community in general? and welfare?

5.4. Are there any LHV/LHWs in your 5.12 What are the areas in which out-of- community? If yes, how many and what pocket costs incur more? (probe into duties do they perform or services they different variables e.g, prevention, provide? treatment and rehabilitation)

5.5. Where do you go if you or one of your 5.13 Are you aware of any initiatives members of family is sick (mildly or currently being undertaken to reduce seriously)? (public or private?) out-of-pocket costs?

5.6. How much does it cost in case of a 5.14 What measures in your opinion can be minor ailment? (include transport, taken to reduce out-of-pocket costs? consultation fee, treatment, medicine and any other expenses) (both public and private)

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